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Cough and angioedema from angiotensin-converting enzyme inhibitors: new insights into mechanisms and management

Dykewicz, Mark S

Current Opinion in Allergy and Clinical Immunology: August 2004 - Volume 4 - Issue 4 - p 267-270
doi: 10.1097/01.all.0000136759.43571.7f
Drug allergy

Purpose of review Angiotensin-converting enzyme inhibitors are widely prescribed for hypertension and heart failure. These drugs are commonly associated with cough, and are less commonly associated with angioedema, which may be potentially life threatening. This review describes data that extend our understanding of the mechanisms of these reactions, and provides guidance about clinical management.

Recent findings For patients who develop angioedema from angiotensin-converting enzyme inhibitors, recent data are reassuring that the majority of such patients can tolerate angiotensin-II receptor blockers. These data support earlier conclusions that most patients with angiotensin-converting enzyme inhibitor-induced cough can tolerate angiotensin-II receptor blockers. Limited case reports suggest that in acute angioedema induced by angiotensin-converting enzyme inhibitors, patients refractory to standard treatment may benefit from the infusion of fresh frozen plasma.

Summary Although data are incomplete, it appears that angiotensin-converting enzyme inhibitors cause cough and angioedema through a cascade of effects that begins with the accumulation of kinins, and then involves arachidonic acid metabolism and nitric oxide generation. Most patients who develop either cough or angioedema from angiotensin-converting enzyme inhibitors can tolerate angiotensin-II receptor blocking agents.

Division of Allergy and Immunology, Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, Missouri, USA

Correspondence to Mark Dykewicz, MD, Division of Allergy and Immunology, Saint Louis University School of Medicine, 1402 S. Grand Boulevard, R209, St Louis, MO 63104, USA Tel: +1 314 977 8828; fax: +1 314 977 8816; e-mail:

© 2004 Lippincott Williams & Wilkins, Inc.